XEROSTOMIA By : Dr Ebtisam Fetohy

Introduction Symptoms & signs Etiology Diagnosis Management

Introduction Xerostomia (dry mouth): Defined by Dr. Huchinson,1898. Is not a disease but a symptom caused by many factors. Dr. Ronald Not all people who complains of xerostomia actually has salivary gland dysfunction.

Salivary Gland Parotid gland – Major source when eating – Serous acini only Submandibular gland – The most responsible when no stimuli – Serous (primarily) + mucous acini Sublingual gland – Only 2-3% of saliva – mucous (primarily) + serous Minor salivary gland – mucous (primarily)

Function of Saliva Lubricationتشحيم Initial digestion of food Modulateتنظم the oral flora Modulateتنظم the oral flora – Immune mechanism: immunoglobulins: IgA, IgG, IgM. Anti-microbial: lysozyme, peroxidase, lactoferrin, agglutinins. Buffering action Buffering action: tooth remineralization Retention of removable denture

Introduction Symptoms & signs Etiology Diagnosis Management Summary

Symptoms & Signs Symptoms: – Oral dryness (most common) – Halitosisرائحة الفم – Burning sensation – Loss of sense of taste or bizarreغريب taste – Difficulty in swallowing – Tongue tends to stick to the palate – Decreased retention of denture

Symptoms & Signs Signs : – Saliva pool disappear – Mucosa: dry or glossyلماع – Duct orifices: viscous and opaque saliva – Tongue : glossitis  fissured  red with papilla atrophy – Angular cheilitis – Rampantالمنتشر caries: cervical or cusp tipرأس القمة – Periodontitis – Candidiasisداء الفطر المبيض

Introduction Symptoms & signs Etiology Diagnosis Management Summary

Etiology Aging Foods & drugs Systemic factors Radiotherapy Sjogren’s syndrome Other salivary gland diseases

Etiology/2 Aging : –Dry mouth: >50y/o:10%, >65y/o:40%. Mashvash N, –46% of 341 subjects (98M, 243F) had noticed subjective xerostomia, more frequent in women. T.O. Narhi, 1994 –Acinar عنقوديةtissue was replaced by fat and connective tissue. Waterhouse, Scott, –When become elder, mucin secretion increase.

Etiology /3 coffee smoke Foods: alcohol, coffee, coco cola, smoke Drugs: – Anti-depressants – Anti-histamine Cimitidine – Anti-cholinergic – sympathomimetic drugs – Anti-inflammatory

Etiology /4 Systemic factors: – Emotions – Emotions: nervousness, excitation, depression, stress.. – Encephalitis, brain tumors, stroke, Parkinson’s dis. – Dehydration – Dehydration: diarrhea, vomiting, polyuria of diabetes … – Anemia, nutrition deficiency.

Etiology /5 Radiotherapy (R/T) – Acini atrophy  fibrosis or replaced by fatty tissue – Serous acini: more sensitive to R/T – Saliva: thickened, altered electrolytes, pH ↓, secretion of immunoglobulins ↓ – >1000 rad (2-3wk): felt oral dryness – >4000 rad: irreversible change

Etiology/6 Sjogren’s syndrome: – Systemic autoimmune disorder, exocrine invasion mainly – 80-90% in female, middle-aged – 1 o sicca الجاف-الملتحمة الجافةsyndrome Xerostomia (82%) Keratoconjunctivitis sicca (KCS) – 2 o sicca syndrome: Sicca syndrome + other autoimmune C.T. diseases (rheumatoid arthritis> SLE> scleroderma, polymyositis…)

Etiology/7 Other salivary gland diseases: – Obstruction or infection of gland – Sarcoidosis, amyloidosis – Benign or malignant tumor – Excision of gland or congenital missing

Etiology/8 Aging Foods & drugs Systemic factors Radiotherapy (>4000rad) Sjogren’s syndrome Other salivary gland diseases  irreversible change  reversible change

Introduction Symptoms & signs Etiology Diagnosis Management

Diagnosis History taking Symptoms & clinical examination Special investigations – Salivary flow rate, SFR – Salivary scintiscanning – Sialochemical analysis & laboratory values – Labial biopsy – Sialography

Salivary Flow Rate (Sialometry) Stenson’s duct Methods: – Resting flow, 10min – Stimulated flow, 10min: citric acid Results: – Resting flow <0.1ml/min  xerostomia – Stimulated flow<0.5ml/min  irresponsive xerostomia Basic, sensitive, time-consuming

Salivary Scintiscanning TC 99 sodium pertechnetate Empty: min Uptake of TC 99 by salivary gland: functional acinar tissue is present High sensitivity, non-invasive

Sialochemical Analysis Saliva: – Na +, K +, IgA, amylase, albumin…. – Lack of specificity Sjogren’s syndrome (SS): have diagnostic value Laboratory Values Sjogren’s syndrome – Elevated ESR, IgG, RF – Positive auto-antibodies: anti-nuclear, ANA anti-SS-A, anti-Ro anti-SS-B, anti-La

Labial Biopsy Chisolm & Mason, 1968: – Minor salivary gland & major gland: high relation – Focus: ≥50 lymphocytes & plasma cells – ≥ 1 focus/4 mm 2 : SS is diagnosed.

Parotid gland: - Slight acinar destruction - Dense lymphocytic infiltrate - Early proliferation of ductal cells

Sialography Instillation of radiopaque fluid into glands – Identification of non-calcified sialoliths & tumors – Unsuitable for diagnosis of xerostomia

Diagnosis History taking Symptoms & clinical examination Special investigations  Salivary flow rate, SFR Stimulated flow  Salivary scintiscanning Sialochemical analysis & laboratory values  Labial biopsy Sialography

Introduction Symptoms & signs Etiology Diagnosis Management

Management Dietary & environmental considerations Preventive Dental Care Measures Saliva stimulatants Saliva substitutes

Dietary & Environmental Considerations Dietary: – Avoid drugs that may produce xerostomia – Avoid dry & bulky foods – High fluid intake & rinsing with water – Avoid alcohol, smoking and sugar – Take protein and vitamin supplements Environment : – Maintain optimal air humidity in the home – Use Vaseline to protect the lips

Preventive Dental Care Measures Smooth sharp cuspsقمم, occlusal groovesأخاديد or fissures, irregular fillings. Check and adjust the denture. OHI. Topical fluoride with carrier use. Fluoride rinses & chlorhexidine rinses. Antifungal medications: – Denture: Miconazole gel, amphotericin or nystatin ointment – Topical: Nystatin, amphotercin suspension or fluconazole..

Saliva Stimulatants Chewing gums Diabetic sweets Sialagogues: – Pilocarpine 5~10 mg, tid Bradycardia, sweating, flushing, urgency of urination, GI upset … – Pyridostigmine

Salivary Substitutes – Carboxy-methyl-cellulose or mucin – Saliva Orthana: contains fluoride. – Mixture of glycerin & citric acid – Natural oral antimicrobial contents: H 2 O 2

Thank you for your attention !!